Dear Daschle: Better Do Your Homework

Guess what emergency medicine fans, it’s now 2009. The election is over and we have spent over a billion dollars deciding who is going to take over this ship of state. Running the United States at this time is like being captain of the Titanic. The difference is the Titanic had a band. We are heading in economic directions that are more than difficult and they are of our own making.

Being a person who has long been interested in presidential politics it is déjà vu all over again, as Yogi Berra would say, to watch the appointments of president-elect Obama. Most important for the emergency medicine community is the appointment of Tom Daschle to take over as the secretary of health. Am I missing something? Is there something in this man’s background that would qualify him to make these decisions? Has anyone, and I mean anyone, in the emergency medicine community ever heard him give a speech where he actually understood the true issues on the table in a dying economy? It looks like more of the same. More bureaucracy, more paperwork, more intentional maligning of physicians and health care providers and less and less understanding of what the rest of the world is doing. I have yet to hear Daschle make one speech in which he references the Germans, the Japanese, the British or any other of the western democracies who seem to be further ahead than we are on all these issues. I would feel much more comfortable if he’d spent a few weeks in Singapore understanding why they can spend about 4.5% of their gross national product on health and have better numbers in longevity and infant mortality than we do.

Mr. Daschle has given no indication in any presentation that he understands the importance of limitations on health care. I want to see someone who will lead a discussion and debate on where we’re going to spend our money. The average citizen honestly has a 1950s view of the government and where it spends its money. Most people believe that the defense department spends most of our money. News flash! Next year, the interest on the national debt – which is soon to top $10 trillion – will be larger than the money we spend on the military. Anyone surprised by this? The only larger expenditure will be that for Medicare and Medicaid. Depending on how one counts the dollars, that only leaves about 8 percent of the federal budget for everything else. Health care will soon be 17.5% of the gross national product. This is up from 3 percent when I was a child. Are we really getting more for our money? How is the Obama administration going to lead a people who have misconceptions, top to bottom, as to what can be accomplished in health care? I believe in change. I applaud the idea of change. But I want real change.

At a certain point, health care can bankrupt the country. The recent problem with the auto industry is the exact best example of where things can go wrong. The big three automakers have as their largest costs legacies and benefits. The Japanese, Koreans and Germans do not have these factors reflected in the cost of each of their vehicles. That difference can be between $1,500 and $2,000 per vehicle, which is a huge amount of money at the lower ends of the cost spectrum. Nothing so far said by the Obama administration or by Mr. Daschle leads me to believe that they’re going to carry on serious discussions about what needs to be eliminated in the system.

If I were advising Mr. Obama, I would suggest that he go on television with a series of discussions with the American people. He needs to revive the Roosevelt fireside chats and talk about the basic health package and what it needs to contain and what we can afford as a people. A country which is $10 trillion in debt is no longer a rich country. We are eroding the value of the dollar faster than we can imagine. The ability of the federal government to take control of the health care system for genuine good is real. But it will not become real if we think we can supply every service to everyone at every hour of the day and night. Why do I spend so much time talking about this? Because the mediator between the public and their desires – many of which are unreasonable – and the health care system, is the emergency department. People present to us at all hours and expect us to do unbelievable things. I once had a woman who, when told that her husband had died of a massive heart attack, looked at me and said, “well just transplant another one!” As if we kept them in jars like oil filters. There is a genuine mismatch between what the public believes we can do (and what the public thinks that society owes it) and what we can afford. If Mr. Daschle wants to take that job, he’d better also take a dose of courage, buy a leather jock strap, and be prepared to take real heat as he talks about the limitations of health care, particularly at the ends of lives. We are the only one of the 17 western democracies that cannot deal with death as a concept. We resuscitate people without brain function. We take people who are dying of metastatic disease and basically prolong their suffering. Until someone is willing to be unpopular in the national press, no one will be able to carry on a real discussion about these issues.

As we head into this brave new world, we need to think seriously about the questions we must ask before we can come up with the answers. So Mr. Daschle, I present to you a challenge: Answer these questions first and then we will be able to talk about what we’re going to do with the health care system.

#1) What is the basic benefit package to contain for the American people and what should they expect they will have to purchase on their own?

#2) How are we going to define end-of-life care and decide what’s going to be done about those people for whom there is no reasonable hope of improvement?

#3) Incredible amounts of poor physician decision-making and overtesting are pushed by the current liability system in the United States. If you expect us to participate in cutting back and in trimming the amount of services given, how are you going to change the current liability climate in America so that the physician can practice reasonable medicine without fear?

Once these questions are answered, I believe we can begin a more intelligent conversation about what’s going to be provided, who’s going to provide it and where we’re going to begin.

Comments

I agree with Dr. Henry's opinion and would add that all efforts should be made by ACEP to educate Mr. Daschle on the critical issues. Emergency Medicine has a unique and perhaps the most accurate perspective on the delivery of health care in this country. I have more confidence in ACEP than I have with the AMA, which I am a member, to elucidate and represent the critical issues that need to be solved. Emergency physicians have a broadest understanding of the delivery of medical care due to our interaction with many specialists and delivery systems in health care.

Shouldn't it be up to the physicians and not the politicians as to how our healthcare resources are allocated? Healthcare is a limited zero sum game. If we give it to someone, we generally must take it away from someone else. There are only so many dollars and so many resources to spread around. As healthcare providers, we need to stand up and take on this responsibility and not let those who truly have no understanding of medical care make these decisions. If we don't take our rightful positions now, we are, in part, to blame for the devastation that will follow.

Additionally, I foresee an issue with paying for the healthcare of others that have brought poor health upon themselves. Examples would include smoking, weight control, drug abuse, and poor exercise regiments. How can we be asked as a nation to pay for these indiscretions?

My solution--although admittedly imperfect--is to have a limited care plan that to pay for healthcare expenses for a brief time during times of devastating medical need and only for those individuals that qualify based on current disability and opportunity for recovery. If an impartial committee of healthcare providers decided the care would be "wasteful", it could and would be withheld. Although this sounds unusual, we must be willing to face the reality of limited resources.

I would also support offering limited prophylactic care, including limited screening exams and support for smoking and drug cessation and diet and exercise. There would also be extra benefits for those that remain on the "righteous" personal healthcare path.

I don't have all the answers, but I'd be willing to help establish a better solution than politicians that have never worked on the front-line of healthcare.

Healthcare is only a zero-sum game if we take money or resources from some people to provide healthcare for other people. In a voluntary transaction that is freely negotiated between a buyer and seller, the game is win-win and wealth is created. This is so because each party in a voluntary transaction believes he got something more valuable than he gave.

Eliminating the third party payers, both government and private "insurers", implicitly solves all the problems of resource allocation that Dr. Henry lists. "We" don't have to decide anything about any individual's health care choices. Each individual can (and should) make the choices about how much of their own resources to spend on their own health care. Problems of resource allocation and zero-sum games only arise when we try to impose collectivist schemes.

A patient-pays model does leave the problem of the small number of people who have insufficient resources to pay for life's necessities. This problem should be solved separately and explicitly and should not cause us to bankrupt the nation in the name of the impoverished few.